1.5 Documenting and Reporting
Guidelines for Documentation
Accurate documentation and reporting are vital to proper client care. Reporting is oral communication between care providers that follows a structured format and typically occurs at the start and end of every shift or whenever there is a significant change in the resident. Documentation is a legal record of patient care completed in a paper chart or electronic health record (EHR). It is also referred to as charting. Checklists and flowcharts completed in the resident’s room may also become part of the paper chart. Documentation is used in a court of law to prove patient care was completed if a lawsuit is filed, with the rule of thumb being, “If it wasn’t documented, it wasn’t done.” Documentation is also reviewed by other health care team members to provide holistic care.
Accurate documentation should follow these guidelines:
- The client’s chart is confidential and should only be shared with those directly involved in care. If using paper, cover information with a blank sheet. When using technology, be sure screens are visible only to you and log out after each use. Never share security measures like passwords or PIN with anyone else.
- Document as soon as any care is completed.
- Include date, time, and signature per facility policy.
- Use facts, not opinions. An opinion is, “The resident doesn’t like their food.” Instead, a fact should be charted, such as, “The resident refused their meal and stated they were not hungry.”
- Use measuring tools, such as a graduated cylinder or a tape measure, whenever possible to provide accurate data. If you do have to estimate, provide a comparison such as, “Drainage noted on the bandage was the size of a quarter.”
- If you chart on paper, always use a black pen. If you make a mistake, draw only one line through the entry, write the word “mistaken entry,” and add your initials. Do not use correction fluid or completely black out the entry.
Long-term care facilities are required to complete additional documentation called a Minimum Data Set (MDS). The MDS is a standardized assessment tool for all residents of long-term care facilities certified to receive reimbursement by Medicare or Medicaid. The MDS is completed by a registered nurse who reviews documentation by nursing assistants to complete some parts of the MDS. Accurate documentation is vital so that facilities are appropriately reimbursed for the services provided to clients.
The MDS nurse will review the nursing assistant’s documentation pertaining to a resident’s sensory abilities, specifically their communication skills, hearing, and vision. For this reason, documentation must be accurate and thorough regarding assistive devices, the amount of assistance required, and skin observations. For example, devices for communication, such as whiteboards, photo books, charts, hearing aids, or glasses, must be appropriately documented, as well as the amount of assistance required for dressing, bathing,